&
Pastoral Care & Counselling
A home-based and congregational
systems ministerial approach in Africa
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All rights reserved. Copyright © 2007 Vhumani Magezi
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First edition 2007 ISBN: 978-1-920109-91-2 e-ISBN: 978-1-920109-34-9 DOI: 10.18820/9781920109349 Set in 10/12 Lucida Bright Cover design by Ilse Roelofse
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PREFACE ... I
ACKNOWLEDGEMENTS ... III
I. INTRODUCTION ... 1
1.1 The Challenge of HIV/AIDS, Poverty and Home-Based Care ... 1
1.2 The Goal of the Book ... 4
1.3 The Rationale for the Book ... 4
1.4 The Proposed Contribution ... 5
1.5 Methodology ... 6
1.6 Outline ... 7
1.7 The Value of the Book ... 9
II. A CONTEXTUAL UNDERSTANDING OF HIV/AIDS ... 11
2.1 Introduction ... 11
2.2 HIV/AIDS Information and the Church in Africa: A Pastoral Resource for Caregivers ... 12
2.3 HIV/AIDS: Definition and Description, Origin, Infection, Transmission and Statistics ... 13
2.4 HIV/AIDS: Infection and Progress in Africa ... 23
2.5 Factors Influencing the Spread of HIV/AIDS in Africa ... 26
2.6 HIV/AIDS within the African Scenario: Sickness in this Worldview, and Perceptions Regarding HIV/AIDS ... 31
2.7 Summary and Conclusion ... 38
III. THE INTERPLAY BETWEEN HIV/AIDS AND POVERTY IN AFRICA ... 41
3.1 Introduction ... 41
3.2 Poverty: Definition and Description ... 42
3.3 Poverty: A Biblical Concept ... 45
3.4 Interplay: Poverty and HIV/AIDS ... 48
3.5 Summary and Conclusion ... 64
IV. THE HIV/AIDS PANDEMIC ... 67
4.1 Introduction ... 67
4.2 The Understanding of Church within a Practical Theological Ecclesiology ... 68
4.3 Towards a Theological Interpretation of Family ... 78
V. PASTORAL COUNSELLING TO HIV/AIDS AFFECTED PEOPLE WITHIN
AN AFRICAN SETTING ... 113
5.1 Introduction ... 113
5.2 Pastoral Counselling: An Interdisciplinary Approach ... 114
5.3 Pastoral Counselling within an African Context ... 130
5.4 Summary and Conclusion ... 170
VI. HOME-BASED CARE: A RESPONSIVE PARADIGMATIC APPROACH TO THE HIV/AIDS PANDEMIC IN AFRICA ... 175
6.1 Introduction ... 175
6.2 The Church as a Subsystem within the Community ... 176
6.3 A Systems Approach and the Principle of Home-Based Care ... 178
6.4 Definition and Description of Home-Based Care ... 179
6.5 Different Models for a Home-Based Care Approach ... 182
6.6 Benefits/Advantages of Home-Based Care ... 187
6.7 Home-Based Care: The Ministerial Praxis of a Family and Systems Orientated Understanding of Ecclesiology ... 188
6.7 Preliminary Conclusion ... 201
VII. SUMMARY OF CHAPTERS, FINDINGS AND RECOMMENDATIONS ... 205
7.1 Introduction ... 205
7.2 Summary of Arguments ... 205
7.3 Findings and Recommendations ... 218
…challenging theology to rethink its major premises about self and society (Miller-Mclemore 2003:xi).
he basic premise of this book is that the congregation is the key to providing home-based pastoral care support to HIV-positive people in poor contexts. In so doing, the church does not only perform a social function to poor HIV/AIDS-affected families, but it also acts in accordance with the calling of mediating God’s Kingdom (diakonia), thus spreading the gospel, and showing unconditional sacrificial love and compassion. The church embodies the gospel, which is the instrument of hope and salvation to despairing people living with HIV/AIDS in the community.
This book attempts to underline pastoral care as a congregational responsibility and not only that of the pastor. The paradigm shift of pastoral ministry from the professional pastor to becoming the responsibility of the whole congregation strengthens the case for congregational home-based pastoral care ministry. The congregation should design a home-based care ministry that functions as an arm of the church in providing support to families and homes affected by HIV/AIDS.
It is presupposed in this book that it has been said, preached and written that the church should be involved in HIV/AIDS care and counselling, which is largely the support function being advocated in this book, but many Christians are still not involved. Among the reasons for this failure is that the current home-care models fail to address the context of poor people, who are the most susceptible and vulnerable to HIV/AIDS. Poverty and HIV/AIDS are intricately linked; hence to be meaningful, ministerial approaches should focus on both issues.
Furthermore, there seems to be no well-articulated theology to inform ecclesiological and congregational HIV/AIDS ministries. Hence, this book attempts to carefully articulate a theology of family derived from Scripture to drive congregational home-based care ministry. In application, the theology draws from the natural African potential (i.e. extended family interconnectedness) in ministry design.
It is argued explicitly and implicitly in this book, based on the inclusive nature of the pastoral care function, that the whole congregation should be involved in loving and providing care (support) for HIV/AIDS-affected people in the community. The suggested practical way to do this is to begin a home-based pastoral care ministry. The proposed model is simply called “congregational/church home-based pastoral care”, but according to Uys’s (2003:5-7) classification, this falls under “single service home-based care”. The model draws from Uys’s three models (i.e. integration, single service and informal home-based care).
The congregation, however, in attempting to provide home-based pastoral care support, faces another hurdle, namely that of poverty alleviation. The church/congregation therefore assumes the paraklesis metaphor (i.e. comforting HIV/AIDS-affected people, and advocating and speaking for HIV/AIDS-affected poor people). It networks with other players (government, NGOs and other churches) in order to address the plight of HIV/AIDS poor people holistically.
In theory formation on the importance of a systems approach (i.e. congregational system care) it is argued that the theological principle of koinonia is fundamental to establishing a caring community and support system that promote faith maturity and spiritual development to the affected people. Thus, in spite of living with HIV/AIDS, the person becomes conscious of God’s faithfulness, that He (God) is present and shares the suffering and pain through his woundedness in Christ, thereby bringing healing. The historical events of incarnation (Jesus’ identification with human weaknesses and problems), crucifixion (paradox of Jesus’ power) and resurrection (Jesus’ victory over all forces) are evidence of God’s involvement with humanity. The counselling “encounter” therefore should theologically be directed by the eschatological perspective in order to promote hope.
The basic theological assumption for the study is that the fulfilled promises of the gospel directed by pneumatology provide a meaningful framework in order to cope with the HIV/AIDS pandemic in a constructive way. Hope emanating from eschatology is a key factor in both prevention care, home-based care and terminal care. It opens up new dimensions to cope with life, despite severe human suffering. It connects ethics with the aesthetics of human dignity.
Firstly, I would like to thank the Lord Jesus Christ whose grace and power strengthened me to work through this study.
Secondly, since this book is a product of a doctoral research thesis, special thanks to my study leader, Professor D.J. Louw, for his wisdom, guidance, emotional support and encouragement that made it possible for me to complete this work.
Thirdly, thanks to various University faculty members who contributed to my success in various ways.
Fourthly, thank you to Stellenbosch University bursary office, Dutch Reformed Church, Faculty of Theology library staff, Pastor T. Manuel and Strandfontein Metropolitan Evangelistic Church, Mr and Mrs G. Bennett, and Dr J.B. Krohn for their financial assistance towards my tuition and general upkeep during this study.
Fifthly, thank you to George Whitefield College, especially through Dr David Seccombe and Dr James B. Krohn, for facilitating my accommodation at their campus under the postgraduate fellowship programme.
Lastly, special thanks to Melody Reavel for making her car available to me throughout this study, and to all my friends at Stellenbosch University, George Whitefield College, the Bible Institute of South Africa and other parts of the world for their support and encouragement.
Introduction
1.1
The Challenge of HIV/AIDS, Poverty and
Home-Based Care
1.1.1 Introduction
The prevalence of HIV/AIDS is high among poor people. The disease strikes very hard in poor countries, and in developed countries the highest incidence is among the poor minority. UNAIDS called it a disease of poverty (World Bank
2002:2)1 and Sub-Saharan Africa is the second poorest region in the world after
South Asia (Gibson and Sandenbergh 2002:17). Therefore, as HIV/AIDS cases escalate in Sub-Saharan Africa, poorly equipped African hospitals and staff are failing to cope. People living with HIV/AIDS are “often discharged home to die because the hospital staff can do nothing further for the patient or because they feel scarce resources are better utilised on someone with greater chances
1 The Department of Social Development publication, Population, HIV/AIDS and
Development: A Resource Document (2003), which is a collaborative report by the
Department of Social Development and the Centre for the study of AIDS, University of Pretoria, stresses that “All evidence points to the HIV/AIDS epidemic being at its most intense and generalised among the poor, affecting the under-employed and unemployed the most” (2003:20).
of recovery” (Jackson 2002:232). Also, some people living with HIV/AIDS may
prefer to be at home with their families rather than in hospitals.2
But when the people are discharged to go home, the poor families get very little
support3 from the government and other social systems (Uys 2003:7). Smart
(Online) aptly notes:
In some developing countries, patients with HIV who have accessed primary care services from government-supported hospitals simply don’t receive palliative care because linkages between these government institutions, community-based organizations and other potential care providers simply do not exist.
The situation, therefore, creates intense physical, psychological, social and
spiritual pressure to the affected4 family5. In this respect, Miller-Mclemore and
Couture (2003:xi), introducing the book entitled Poverty, Suffering and HIV/AIDS, which is a record of papers delivered at the International Academy of Practical Theology at Stellenbosch, South Africa, 2001, posed crucial and fundamental reflective questions for theology. Thus,
How do the churches relate to society? What does the problem of global and local poverties mean for the practices of ministry within the church? And how are these relationships and practices grounded in Biblical and theological perspectives?
2 Ncube’s (2003:104) article “Responsibility in Inculturation: The healing Ministry in a Zulu
Context” focuses on how HIV/AIDS fits into the Zulu context and worldview, which may be the general case in Africa. He attests to the fact that it is important for Zulus or African people who are seriously sick (including HIV/AIDS) that they should come azofela
ekhaya (to come and die at home).
3 Such support includes ongoing emotional and spiritual counselling, financial assistance,
help with food, cooking, cleaning, wound care, hygiene, symptom assessment, pain and symptom management, identification of specific opportunistic infections, etc.
4 Affected people refers to the HIV-infected person and the family caregivers.
5 The Department of Social Development, South Africa (2003:42) further observed and
commented that an analogy can be made between the impact of HIV/AIDS on the body and its impact on society’s core institution, the family. In attacking the immune response of the body, HIV sets in motion a series of infections that exhaust the body’s reserves, inhibit its capacity to resist disease and force it to use up essential muscle and fat in a desperate struggle for life until all is consumed. In attacking adults in their core productive and reproductive years, the social impact of the epidemic is the destruction of the family, a core institution that is at the centre of sustained human existence. As families try to defend themselves against the epidemic, they deplete their reserves, reducing their food intake and their capacity to meet their general care responsibilities. In their struggle to survive they lose anchor, as the people, capacities and material necessities that make collective life possible are consumed, stripping the family of its basic conditions of existence. This process continues through society, eroding if not destroying all levels of social organisation. In such a context, without strategic intervention, the family, like the body, cannot withstand the onslaught and human as well as social survival is threatened.
1.1.2 The Problem
In the light of the above introduction, the following questions help to focus this book:
[ What is the link between poverty and the HIV/AIDS pandemic in an African
context?
[ In terms of crisis management, how can pastoral care play a role in
providing a support system to poor families, especially during the crisis stage as well as during the final stage of terminal care?
[ How can the concept of home-based care be applied to a model in which
the congregation becomes a caring community, reaching out to the needs of HIV-positive people without the luxury of a sophisticated medical care system?
1.1.3 The Hypothesis
In order to provide a support system to people suffering from HIV/AIDS within a poor community setting, the pastoral ministry should move away from a very
sophisticated counselling room approach to a congregational6 systems7
approach, which is focused not only on the congregation but also on the needs, pain and suffering of the community and society. For this approach, a model of
home-based care8 is proposed.9 Through designing an HIV/AIDS home-based
6 There is a paradigm shift in pastoral care from the “professional pastor” approach to
mutual care of believers, i.e. faith community care (koinonia) (Crabb 1979; Louw 1998). This is in line with Hendriks’s (2004:14-16) argument in Studying Congregations in Africa. He rightly emphasises that the congregation should be the fundamental locus of congregational studies, which in our case is congregational (koinonia) care. His arguments can be summarised as follows: firstly, the congregation is the first and foremost manifestation of the church – if it fails, then there is little hope elsewhere. Secondly, a congregational (koinonia) focus implies empowering members (laity), which enables congregations to grow spiritually rather than to be mere recipients (which makes them spiritual dwarfs - immature). Thirdly, it allows for congregation members to act and respond in accordance with the realities of their situations – the reality of diversity and pluralism. Fourthly, due to globalisation, the focus on congregations allows people (members) to deal with issues in their own environments, as these realities are in and around them, e.g. HIV/AIDS and poverty. Fifthly, it promotes a bottom-up approach in which people participate on issues that concern them.
7 Augsburger (1986:178) states that a system is a structure in process; that is, a pattern of
elements undergoing patterned events. The human person is a set of elements undergoing multiple processes in cyclical patterns as a coherent system. Thus a system is a structure of elements related by various processes that are all interrelated and interdependent. A systems approach does not focus on the person and psychic composition, but notices a position held by a person within a relationship (Louw 1998:74), which makes it crucial in Africa, considering the people’s connectedness. A broken relationship affects the whole being.
8 The AIDS Bulletin (2004:4) argues that home-based care is identified as one of the
non-ARV options, which should be scaled up with the same vigour as non-ARV. And it is being ignored as a proven cost-effective intervention in the rush for ARVs.
pastoral care ministry, the congregation (koinonia of believers)10 could reach
out and provide support to the affected people (enfleshment of agape), which is the calling of the church. In so doing, the church does not only perform a social function to the poor HIV- and AIDS-affected families, but it also acts in accordance with the calling of mediating God’s Kingdom. Thus, spreading the gospel (Word and deed), showing unconditional sacrificial love and
compassion, which is enfleshment or embodiment11 of the gospel. The
identification with the suffering of the person dying of HIV/AIDS should be viewed as instrumental to home care and the enactment of salvation, which is
the impetus of hope.12
The presupposition for a home-based model is that the more one has to deal with poverty and is exposed to the suffering of people in an African setting or rural context, the more pastoral care should make use of and draw upon the so-called “natural” and “immediate” sources of people within the community. In order to do this, one should understand African spirituality as a people-oriented, interrelational system.
1.2
The Goal of the Book
The book outlines how HIV/AIDS home-based pastoral care and counselling within a congregation can be done effectively to provide a support structure for poor people affected (i.e. the HIV-infected person as well as the family providing care) by HIV/AIDS. This is done within an awareness of the impact of the HIV/AIDS pandemic within the African context. In this regard, an African perspective and reflection play a decisive role as well as an understanding of the basic worldview and philosophy of life within African spirituality.
1.3
The Rationale for the Book
The HIV/AIDS pandemic gives cause for concern for all people in Sub-Saharan Africa. It is hard for one not to have witnessed an HIV- and AIDS-related death, and the situation is compounded by the intricate relationship between the disease and poverty. Poverty provides the social context within which the
pandemic flourishes in Africa and South Africa (Pienaar 2004:6; UNAIDS 4th
global report 2004; Department of Social Development 2003:20). The link is
10 The word koinonia refers to the fellowship, association, community, communion, joint
participation of believers (Thayer 1977:2844). And it is used in this research to describe the mutual care of the faith community members.
11 The church is challenged regarding HIV/AIDS to recognise the need to overcome fears, to
be signs of hope in our afflicted world, to share our pain and the pain of others, to fight denial, to work for reconciliation and hope (Munro 2003:48).
12 God’s healing grace is communicated through pastoral care metaphors (i.e. shepherd,
servant, paracletic and wisdom); by so doing, both the pastor and parishioners become crucial vehicles of God’s healing grace amid HIV/AIDS despair.
clearly stated in a report by the UNAIDS (World Bank 2002:2 only 2001) on the distribution of HIV/AIDS around the world:
AIDS is a disease of poverty in the sense that most of the people with HIV or AIDS are poor. The disease struck very hard in poor countries: 96 percent of infected people are in the developing world, and 70 percent are in Sub-Saharan Africa alone.13
Furthermore, the World Bank report asserts that studies in developed countries show that AIDS is most prevalent among the poor.
Sub-Saharan Africa being the second poorest after South Asia (Gibson and Sandenbergh 2002:127), and leading in HIV/AIDS cases, the challenge is far from being the responsibility of only governments or social workers. The church, especially in the area of pastoral care and counselling, is inevitably expected to offer support, love and hope to HIV- and AIDS-affected people. “In fact, pastoral care is one of the services generally available in Sub-Sahara Africa” (Smart online). It is the characteristic of the Church to love (agape) and care. And it is into this challenging task of supporting (showing solidarity with) HIV/AIDS-affected people within their context, in our case one of poverty, that pastoral care is expected to be implemented.
The theological presupposition of the study is that God is faithful in every situation, even in HIV/AIDS infection due to his (God’s) identification with suffering people. The introduction of such a theological principle is connected to a very specific God-image: God’s identification with suffering people due to his own woundedness through and within the cross of Christ. Pastoral care should therefore proceed from a thorough understanding of a theologia crucis. Furthermore, pastoral care should be a conduit of God’s faithfulness in order to bring hope to the people suffering from HIV/AIDS within a context where poverty prevails. Pastoral therapy, which operates from an eschatological perspective, should try to foster a vivid hope (Louw 1998: 449). This hope can play an important role in the process of coping with the infection in a constructive way and manner.
1.4
The Proposed Contribution
The HIV/AIDS pandemic is a big challenge in Africa, especially in Sub-Saharan Africa. The hospitalisation paradigm of caring for the sick is failing to cope. Hence, the home-based care paradigm for HIV/AIDS caring could be a possible
13 The AIDS Bulletin (2004:3) also attests to the correlation between HIV/AIDS and poverty
in saying: “We know that HIV/AIDS is the quintessential disease of poverty. The pandemic has its greatest impacts on the poor and most vulnerable populations: those with no access to clean water and sanitation; poor nutrition and overall health status – and those who are constantly challenged by a variety of other infections”.
solution.14 In this regard, however, the communal concept of Africans –
umunthu ngumunthu ngabantu (a person is a person because of people, or a person is a person through other persons) – is instrumental and an invaluable building block concept contributing to successful and effective congregational
(koinonia) home-based care.15 The church, in executing her pastoral care role,
should utilise this rich and advantageous concept in addressing the needs of HIV/AIDS-affected people. The book, therefore, carefully explores and reports on the age-old activity of home care or family care in Africa and the biblical tradition, and the challenge of poverty, thereby drawing lessons on how pastoral care and counselling can be undertaken effectively to provide care and support HIV/AIDS-affected people.
1.5 Methodology
[ The book is a product of a literature study. A sufficient number of sources
were found on the issue of HIV/AIDS and its link to home-based care for a literature-based approach.
[ The method of critical reflection as well as analysis and logical arguments
was applied in order to understand the pandemic and to argue the hypothesis.
[ A hermeneutical approach was followed in order to gain clarity on the link
between the HIV/AIDS pandemic and theological reflection. Thus the method of interaction between theory and praxis, praxis and theory.
[ Indirectly, the researcher made use of the method of participatory
observation due to the fact that his context was reflected in his own subjective mindset. He originally comes from Zimbabwe and has been is South Africa for several years, where the immediate context of the HIV/AIDS pandemic impacts on his attitude and aptitude.
14 The available publications, however, do not adequately address the subject of
home-based care. They either completely ignore it, or mention it in passing, e.g. the publications listed below:
Ackerman (2001), Barret-Grant et al. (ed.). (2003), Bate (ed.). (2003), Byamugisha et
al.(2002), Cadwallader, A.H. (ed.), Dube (ed) (2003), Gennrich (ed.). (2004), Grenz and
Hoffman (1990), Greyling and Murray (2004), Greyling (2001), Hunter (2001), *Jackson (2002), Lachman (1999), Louw (2001), Pienaar (2004), Porte (2003), Shelp and Sunderland (1987a, 1987b), *Van Dyk (2001, 2000), Van der Walt, (2004), Ward (2001), World Council of Churches document: Facing AIDS: The challenge, the Churches’ response.
* These authors mention home-based care but do not discuss it in detail.
It seems the only publication that deals with the subject of home-based care is: Uys and Cameron’s (ed). (2003) publication. The authors of the book rightly comment that it is the first book that addresses the subject. In addition, some publications on the general subject of HIV/AIDS are totally misleading. They claim to address the African scenario and yet they completely ignore it. An example is the publication by Mombe (2004), a Jesuit from the Central African Republic.
15 Hence the concept that an individual does not exist on his/her own, for a person is a
person through and with others (umuntu ungumuntu ngabanthu). Similarly, in the Christian tradition, people live as a body of Christ (1 Cor 12).
[ In terms of doing theology, practical theology is defined as a continuing hermeneutical concern discerning how the Word (Scripture) should be proclaimed in word and deed in the world (Hendriks 2004:19), which Louw (1998:4) referred to as “theology from below”. Hence, the following guidelines of doing theology echoed by Hendriks (2004:24) will be adopted: Theology is about:
[ The missional praxis of the triune God, Creator, Redeemer, Sanctifier, and
[ About God’s body, an apostolic faith community (the church)
[ At a specific time and place within a globalised world (a wider contextual
situation)
[ Where members of this community are involved in a vocationally based,
critical and constructive interpretation of their present reality (local analysis)
[ Drawing upon an interpretation of the normative sources of Scripture and
tradition
[ Struggling to discern God’s will for their present situation (a critical
correlation hermeneutic)
[ To be a sign of God’s kingdom on earth, while moving forward with an
eschatological faith-based reality in view (that will lead to a vision and mission statement)
[ While obediently participating in transformative action at different levels:
personal, ecclesial, societal, ecological and scientific (a doing, liberating, transformative theology that leads to a strategy, implementation and evaluation of progress).
1.6 Outline
Chapter 2 outlines a contextual understanding of HIV/AIDS in Africa. It argues that understanding the African worldview of sickness and how HIV/AIDS fits into this framework, coupled with accurate HIV/AIDS facts and information, is the key to effective pastoral care to HIV/AIDS-affected people. Thus this chapter provides the background information both on an African personalistic and a naturalistic understanding of HIV/AIDS that is crucial for caregivers in Africa. The discussion falls under the following subheadings: the strategic nature and effectiveness of the African church in disseminating HIV/AIDS information; facts on HIV/AIDS issues such as definition and description, origin, infection, transmission and statistics; infection progress; factors contributing to the rapid spreading of the epidemic; and an African worldview of sickness and how HIV/AIDS fits into the framework.
Chapter 3 delineates the nature of the relationship between poverty and HIV/AIDS in Africa. The discussion falls under the following subheadings:
definition and description of poverty; biblical concept of poverty (both in Old Testament and New Testament); and interplay of poverty and HIV/AIDS.
However, since poverty and HIV/AIDS are global phenomena, it is insightful to consider the African scenario (i.e. the sub-Saharan region) in the light of global issues and processes. Therefore, Chapter 2 and Chapter 3, according to our definitional framework of doing theology, fall under: God’s body (faith community - the church) at a specific time and place within a globalised world (a wider contextual), where members (faith community) are involved in a critical and constructive interpretation of their present reality (local analysis).
Chapter 4 outlines a practical theological ecclesiology within a context of poverty and HIV/AIDS. It argues the assumption that for pastoral care to be effective and meaningful in addressing the plight of poor and HIV/AIDS-affected people, the church i.e. koinonia, should embody the metaphor of family, whose members, through a systemic relationship, have a responsibility to care for one another. The focus therefore ceases to be on the individual but on the whole community (system), which encourages care and support for one another. The congregation systems approach also helps congregations to shift from apathy to empathy, i.e. from non-involvement to active participation in the lives of the poor and HIV/AIDS-affected people, which is a translation of the gospel into reality (enfleshment of the gospel). The discussion falls under the following subheadings: definition and description of church; the practical theological nature of the church; church (koinonia) family systems approach; African extended family care system; biblical (both Old Testament i.e. Jewish, and New Testament) injunction and paradigm of care; comparison of biblical and African family caring; and change of attitude to the poor and HIV/AIDS-affected people.
According to the definition of theology, this entails drawing upon an interpretation of the normative sources of Scripture and tradition, and struggling to discern God’s will for their present situation (a critical correlation hermeneutic). Thus the methodology of theory-praxis, praxis-theory.
Chapter 5 outlines pastoral counselling intervention to people living with HIV/AIDS. It argues the assumption that pastoral counselling is the most appropriate approach, which deals meaningfully with healing and providing hope to people living with HIV/AIDS from the disclosure of their HIV status until death through faith-community (kononia) care. By designating pastoral care metaphorically – shepherd, wisdom, servant and paraklesis – it embodies God’s healing grace. The discussion falls under the following sub-headings: definition and description of pastoral care; counselling stages, pre- and post-HIV test counselling; the distinctiveness of pastoral counselling; a heath relationship between psychology and the Bible; the nature of pastoral therapy; pastoral diagnosis/assessment; and basic counselling skills.
Chapter 6 focuses on a design for a home-based pastoral care ministry as a responsive paradigm to the HIV/AIDS pandemic in Africa. The congregation within its community should erect structures that support HIV/AIDS-affected people in the church and outside (in the community). The selfless giving, unconditional sacrificial love and compassion taught in Scripture that is epitomised in the Lord Jesus Christ’s sacrificial death on the cross for humanity should be the motivation for congregation members. The chapter assumes that by drawing lessons from the notion of the extended family in Africa, home-based care ministry is imperative to ministerial practice in Africa. The discussion falls under the following subheadings: home-based care – definition and description, advantages of home-based care, origin and models of home-based care; and home-based care ministry design.
Chapters 5 and 6 deal with how a church can give practical assistance in a context of poverty and HIV/AIDS, i.e. translating the theological and pastoral perspective to the reality of human suffering. Thus these chapters mean that a faith community (kononia) becomes: a sign of God’s kingdom on earth, while moving forward with an eschatological faith-based reality in view (that will lead to a vision and mission statement) and obediently participating in transformative action at different levels: personal, ecclesial, societal, ecological and scientific (a doing, liberating, transformative theology that leads to strategy, implementation an evaluation of progress).
1.7
The Value of the Book
It is envisaged that this book would be a resource for HIV/AIDS caregivers, faith-based NGO programme planners, church leaders and counsellors. Furthermore, it would encourage African churches to draw from their history and culture in order to help Christians to develop a practical approach towards those suffering from poverty and HIV/AIDS in ways that are familiar to the cultural context of Africans as well as being rooted in Scripture.
A Contextual Understanding
of HIV/AIDS
The African Scenario
2.1 Introduction
Christianity should be context- and situation-relevant in order to be effective. Hendriks (2001:76) underlines this idea in the article “Doing Missional Theology in an African Context”, in which he states that “Doing theology and being a church is a process where we accept that all theological formulations and institutional designs are influenced by their context”. Thus, theology is contextual. Couture (2003: xii), arguing along the same lines as Hendriks, states that “different parts of the world must develop practical theological methods that are the most responsive to the critical questions that are raised in particular locations”. Hence, it is important for us to reflect on the African HIV/AIDS context and scenario. This chapter therefore focuses on the African contextual understanding of HIV/AIDS.
The chapter proceeds from the assumption that understanding African people’s personalistic worldview of sickness (i.e. sickness caused by supernatural beings) and how HIV/AIDS fit into this framework is crucial for effective pastoral care. Thus, though African people may embrace naturalistic explanations (i.e. sickness caused by natural causes) of HIV/AIDS, it is interpreted within the personalistic framework. Therefore, crucial as the
naturalistic facts and information on HIV/AIDS may be, the African worldview should be understood as well.
Secondly, the chapter assumes that highlighting important HIV/AIDS facts and information and how they fit within the African worldview provides the core background information for the church to provide effective pastoral care support. But what is the HIV/AIDS information that a pastoral caregiver and counsellor should know in order to counsel effectively in Africa? What is the
role of the African church1 regarding HIV/AIDS information? And, importantly,
what is the African worldview of sickness and how does HIV/AIDS fit into this framework?
2.2
HIV/AIDS Information and the Church in Africa:
A Pastoral Resource for Caregivers
The church in Africa should be aware of HIV/AIDS information. It is deplorable that church people (i.e. pastoral caregivers) and leaders should be ignorant about their HIV/AIDS context. An example of such deplorable ignorance was uncovered by Forster’s statistics (cited by Brown 2004:59) in Malawi:
[She] found that ministers of religion were seen to be not only among the least reliable as a source of information regarding HIV/AIDS, but they were also not perceived as being particularly credible nor trustworthy in terms of AIDS messages.
The need for pastoral caregivers, who are congregation members, to be acquainted with HIV information is undoubtedly of strategic and paramount importance. People from different localities converge at church meetings for worship. According to the first comprehensive research in South Africa that was done by the Nelson Mandela HSRC study of HIV/AIDS (NMH), it was discovered that “Faith-based organisations were an important source of HIV/AIDS information and rated higher than AIDS organisations, youth groups and sports clubs” (2002:17). Hence the church should exploit this advantage to inculcate more knowledge that would hopefully lead to behavioural change. Besides, Mwaura (2000:96) in his article, “Healing as a Pastoral Concern”, adds that “the pastor responsible for providing pastoral care has also a duty to be well informed about the disease for his/her irrational fear can cause additional pain and harm to the victims and those who attempt to care for them”. The research report (NMH 2002:15) further underlined the value of information, saying:
1 The phrases African church and church in Africa synonymously refer to churches that are
located in Africa. They can be mainline churches or African-initiated churches, but they experience the same challenges and opportunities.
Better knowledge of transmission has been shown to have positive relationship with both prevention behaviours and positive attitudes to people with HIV/AIDS. This does not imply that knowledge is a sufficient condition of behaviour change and positive attitudes, but is necessary condition.
Information should be disseminated to all church members in order for them to be aware of the crucial facts. Louw (1995:32-33) in his article, “Pastoral Care for the Person with AIDS in an African context” rightly states that “soberness and realism have prevailed” regarding HIV/AIDS in Africa. And the focus of pastoral care (i.e. provided by the church) is now twofold: “information, education, and the creation of adequate emergency services, care and support systems within local communities” (my emphasis) (1995:33). HIV/AIDS information is no doubt crucial for the caregiving community. But, what is the HIV/AIDS information that pastoral caregivers are supposed to know in Africa? Ackerman (2001:5), referring to the HIV/AIDS situation, argues that we are all people with HIV/AIDS because many of us are infected. Thus HIV/AIDS has become intricately entangled with our being. Therefore, the complex issues related to Africa’s epidemic are intertwined with some African cultural issues and worldview. Hence, it is insightful to provide an overview of HIV/AIDS information (2.3) in the light of the African worldview (2.4).
2.3
HIV/AIDS: Definition and Description, Origin, Infection,
Transmission and Statistics
HIV/AIDS definition and description: AIDS is the acronym for acquired immune deficiency syndrome. It is a condition caused by HIV i.e. the human immunodeficiency virus. The HI virus enters the body from outside (i.e. it is acquired) and destroys the immune system that defends the body against infection. When the body’s immunity is weakened, this is called immune deficiency. Because the body no longer has immunity to fight against any infection, it becomes open to any infection. A syndrome therefore “refers to a set or collection of specific signs and symptoms that occur together and that are characteristic of a particular pathological condition” (Van Dyk 2001:4). Rebirth African Art (Online) simply stated, “HIV/AIDS cause an immune-system breakdown rather than a specific disease, so people can die of any one of dozens of diseases that have been here in Africa for decades”.
Although AIDS is called a disease, it is important to emphasise that it is not a specific illness, but a collection of many different conditions that manifest in the body because the HI virus has weakened the immune system. The body can no longer fight the pathogens that invade the body. Hence it is more accurate to define AIDS as a syndrome of opportunistic diseases, infections and certain
cancers - each or all of which have the ability to kill the infected person in the final stages (Shelp and Sunderland 1987:11; Grenz and Hoffman 1990:63-74; Van Dyk 2001:5).
However, for a general working technical definition, it is worthwhile to adopt the definition below by Avert (Online).
The Centre for Disease Control (CDC) currently defines AIDS in an adult or adolescent age 13 years or older as the presence of one of 26 conditions indicative of severe immunosuppression associated with HIV infection, such as Pneumocystis carinii pneumonia (PCP), a condition extraordinarily rare in people without HIV infection. Most other AIDS-defining conditions are also “opportunistic infections” which rarely cause harm in healthy individuals. A diagnosis of AIDS is also given to HIV-infected individuals with a CD4+ T cell count less than 200 cells per cubic millimeter (mm3) of blood.
While it may be necessary to flesh out this definition, for the sake of the researcher’s and the intended theological audience’s limited knowledge of the technicalities, we shall focus on less technical facts that are easily digestible and relevant for the discussion. What is crucial, however, is for caregivers to distinguish between AIDS and HIV. AIDS is the final stage of immunity depletion by the HIV [NOT: HIV=AIDS; but HIV will cause the AIDS condition]. AIDS is a condition that renders the body vulnerable and exposed to any kind of invasion (pathogens), because the HIV has eroded the body’s defence system. However, the difficulty of distinguishing between HIV/AIDS in the discussion prompts the following question: why is it important to differentiate HIV from AIDS?
The response to the above question has implications for the HIV/AIDS caregivers, counsellors and infected people. It raises awareness among the affected people that being diagnosed as HIV positive is not a death sentence. There are still many more years to live, provided the person adopts the right attitude and behaviour. As for the counsellor, it allows him/her to offer precise or accurate guidance and constructive advice to HIV/AIDS-affected people. But what is the origin HIV?
HIV origin: In the past people used to call AIDS a homosexual disease both in Africa and in the West. But most people now do not view HIV/AIDS in this way. There is consensus that the HI virus causes AIDS and the only way to trace the origin of AIDS is to trace the HI virus. However, the Origin of AIDS and the HIV group (Online) warned that in trying to identify where AIDS originated, there is danger that people may try to use the debate to attribute blame for the disease to a particular group of people or individuals or certain lifestyles. Therefore,
the quest to unveil the roots of HIV/AIDS should be dissociated from stigmatising and ostracising particular people.
There are many unfounded and speculative theories about the origin of HIV. For instance, some say the HI virus was developed as an instrument of biological warfare; it was being used by aliens from outer space to kill people of planet earth (Shelp and Sunderland 1987:7; Grenz and Hoffman 1990:35; Van Dyk 2001:6-8); it is God’s punishment; it resulted from polio vaccines in central Africa (Jackson 2002:3-6), and many others. All these theories are suspect; hence, it is unwise to dwell on them. The question remains: what is the probable origin of HIV?
Regarding the origin of the HI virus, it has been scientifically established that the HI virus belongs to a group of viruses called lentiviruses. Lentiviruses other than the HI virus have been found in non-human primates (such as chimpanzees and African green monkeys). These other lentiviruses are known as “simian monkey viruses”, i.e. simian immunodeficiency virus (SIV). Kober affirms that the link between the SIV and the HIV is generally accepted by scientists, i.e. HIV crossed species from primates to humans at some time during the twentieth century (cited in Van Dyk 2001:3-6).
The crossing occurred because certain viruses can pass from animals to humans, and this is called zoonosis. Therefore it is believed that HIV could have crossed over from chimpanzees to humans through their being killed for food or through vaccine (but evidence of vaccine seems to be rejected). There are no conclusive facts about how the virus crossed from one species to another. But the earliest instances of HIV infection are from a man in the Democratic Republic of the Congo (1959); the “British sailor from Manchester who died of an AIDS-related illness in 1959” (Lachman 1999:8); HIV was found in an African American teenager who died in St. Louis 1969; and HIV was found in tissue samples of a Norwegian sailor who died in 1976.
With such an avalanche of speculative data, it is wise therefore to accept the following comment on the origin of AIDS and HIV (www.originofaids.com/ 2002:2):
We will probably never know exactly when and how the virus first emerged, but what is clear is that sometime in the middle of the twentieth century, HIV infection in humans developed into the epidemic of disease around the world that we now refer to as AIDS.
Origin of AIDS.com (Online), in “The origin of AIDS and HIV may not be what you have learned”, surveyed the scientific data available and concluded with the words of prominent scientists. They wrote:
Myers and his colleagues offered the following best explanation for the origin of HIV: “It is not far fetched”, they wrote, “to imagine the ten clades deriving from a single animal (perhaps immunosuppressed and possessing a swarm of variants) [as might have been the case with chimpanzees used in the process of vaccine manufacture] or from a few animals that might have belonged to a single troop or might have been gang caged together. The number of animals required is secondary to the extent of variation in the source at the time of zoonotic or introgenic event. The (vaccine) hypothesis makes a case for such a punctuated origin.
Nonetheless, the conclusive fact backed by scientific research is that there are two HIV strains, HIV-1 and HIV-2. HIV-1, which is more virulent and has spread throughout the world, originated in the chimpanzee sub-species. A particular kind of chimpanzee is known to carry a virus quite similar in structure to the HIV. The HIV-2, which is less virulent, is found in West Africa and originated from the sooty mangaby monkey (Greying and Murray 2004). Once the HI virus was in the blood, the rapid and sudden spread of the HI virus was largely due to international travel, the blood industry and drug use (Jackson 2002; Van Dyk 2001, among many other writers). To close the debate on the origin of HIV, it is wise to note that wasting time arguing about who caused the fire while the house is burning is foolish. While knowing the perpetrator may be necessary, it will not put out the fire. The wisest thing is to call the fire brigade. So it is the same with trying to know the origin of HIV/AIDS. People are in a serious predicament. They should look ahead for ways to adapt. HIV/AIDS-affected people need care. (For a detailed discussion visit: www.avert.org/ origins.htm) HIV infection: The HIV-1 is believed to be the cause of infections in Central, East and Southern Africa, North and South America, Europe and the rest of the world. HIV-2 was discovered in West Africa (Cape Verde Islands, Guinea-Bissau and Senegal) in 1986 and it is mostly restricted to West Africa (Jackson 2002:145; Van Dyk 2001:5). Both viruses cause AIDS, but the difference is that
HIV-2 works slowly on the victim, thereby taking a long time for the victim to develop AIDS symptoms.
The immune system (i.e. the body’s defence mechanism) has several different methods of fighting infections, some of which are the white blood cells, i.e. phagocytes and lymphocytes (T cells and B cells). The T4 or CD4 cells activate other cells to fight against infection in different ways. They also destroy the cells infected with viruses. And it is these (T4 or CD4) cells that are affected by HIV, thereby making them ineffective. In addition, HIV invades dendritic cells that alert the CD4 cells to the presence of the foreign bodies (i.e. infections). When they are destroyed, the response of the CD4 cells will be very weak. The destruction of the immune system means that infections can occur in the body unchallenged and multiply to cause serious diseases.
The complexity and unique challenge of HIV derive from its ability to mutate or change rapidly. HIV mutates or changes its outer layer so rapidly that it is extremely difficult to detect any similarity between the outer layers of one HI virus and the next. Because of this rapid mutation, the body cannot defend itself against the enemy, because its enemy is constantly changing its identity (Shelp and Sunderland 1987:11; Grenz and Hoffman 1990: 63-74; Van Dyk 2001). Louw (1990:37-38), in Ministering and Counselling the Person with AIDS, added, “The virus changes frequently and has the ability to adjust itself. Its genetic plasticity creates a very fluid situation and makes medical research difficult”.
Spreading HIV/AIDS: There are four body fluids that contain high HIV concentrations in an infected person and show evidence of transmission: blood, semen, vaginal fluid and breast milk. But saliva, tears, perspiration and urine have low HIV concentrations and there is no evidence of transmission. In fact, for HIV to be transmitted through them, they need to be present in large quantities, e.g. seven gallons of saliva. Therefore, transmission focuses on the four highly concentrated fluids that can be passed from the infected person to the next largely through sexual intercourse, blood transfusion, and by way of parent to child (mother to child).
Sexual intercourse: HIV infection is mostly transmitted sexually through unprotected vaginal or anal intercourse (without a condom), and possibly but very rarely through oral sexual contact (Shelp and Sunderland 1987:9; Grenz and Hoffman 1990:23; Van Dyk 2001:18). In South Africa, which could also be the case in other African countries, sexual HIV transmission is responsible for 86% of cases (i.e. 79% heterosexually and 7% homosexually) (Greyling and Murray 2004). Thus HIV in Africa is chiefly transmitted heterosexually. HIV is transmitted when the virus enters the blood stream via the body fluids and connects to the CD4 cells. Women are more vulnerable to being infected with the virus because of physiological, anatomical and socio-economic factors, and
age.2 Statistically, a single unprotected sexual encounter with an infected
person is enough for an infection to occur.
Contaminated blood: The HI virus can be transmitted when a person receives contaminated blood during blood transfusion; this accounts for 1% of the HIV cases in South Africa. Even though there are far fewer cases of HIV transmission through blood transfusion than sexual transmission, there are cases where people have been infected through contaminated blood. To avoid such incidents, the WHO stipulated strict precautions to guard against blood
contamination by the HI virus.3 The blood should be thoroughly screened.
Apart from blood transfusion, people who share syringes and needles to inject drugs are also at high risk. UNAIDS 2000 estimated that nine out of ten cases of transmission of HIV among heterosexuals in New York can be traced back to having sex with a drug user who receives drugs intravenously (Van Dyk 2001:25).
Needles, syringes and other sharp instruments either in hospitals or used in piercing or cutting, such as circumcision, may expose people to the HI virus. Parent to child (i.e. direct mother-to-child transmission): Mother-to-child HIV transmission is responsible for HIV cases in young children, and accounts for 13% of the HIV cases in South Africa. However, mother-to-child transmission (MTCT) is preferably called parent-to-child transmission (PTCT), since the mother might have acquired the HIV from the spouse. PTCT transmission takes place during pregnancy (approx. 6%), during labour and delivery (approx. 18%) and during breastfeeding (approx. 4%) (Ray et al. 2002:21; Greyling and Murray
2 Physiologically: The lining of the vagina strengthens at the age of 15-16 at the stage
when the body produces hormones to prepare a girl’s body for sex. Therefore, if a girl has sex before that, there are high chances of lesions, thereby increasing the risk of infection. Furthermore, the PH balance and different bacteria in the vaginal area, if altered, provide a suitable environment for the HIV. Also, due to periodical discharges, she may not know when she has an STI, thereby increasing the risk of infection.
Anatomically: Women are receivers of semen; they experience more trauma to their sexual organ, which leads to lesions, especially during dry sex; and women’s genitals are mostly internal and they won’t notice any lesion or discharge.
Socio-economic: Often in many cultures women are economically disadvantaged and they have little power to negotiate for contraceptives; they are often objects of abuse; and in rural areas there is no access to health care services for the treatment of STI that reduces HIV transmission.
Age: Women are more susceptible to infection at a younger age because their bodies are not ready for sex and yet they become sexually active early; and the young girls also prefer having sex with older men who give them gifts and the older men in turn prefer young girls too.
3 The blood of all donors is tested every time they donate blood; with each donation the
donor is asked to complete a questionnaire on his/her sexual activities to determine whether he/she should donate; all blood products, such as factor viii and plasma, are subjected to heat treatment or chemical cleansing processes that destroy all possible viruses; where possible blood transfusion services use donors about whose lifestyles they are relatively certain, their blood is nonetheless still tested; and sterile needles are used every time.
(2004:3.4/23). HIV infection can occur in early pregnancy and many of these pregnancies end in miscarriage and stillbirths. But the main transmission of HIV during pregnancy occurs during the last three months or during labour and delivery. Postnatal HIV infection occurs through breastfeeding.
Administering antiretrovirals, e.g. Nevirapine, controls transmission during pregnancy; delivery through caesarean operations controls infection during
delivery; and safer breastfeeding4 or replacement infant feeding controls
postnatal infection. However, though PTCT can be reduced, it is hampered by poor antenatal care in Africa because of the poor medical facilities prevalent among the vulnerable poor HIV/AIDS majority. And replacement feeding for the infant has a cultural stigma. Ray et al. (2002:x) in Parent to Child Transmission of HIV highlight similar issues in Africa in agreement with Nierkerk’s (2003) article “Mother to Child transmission of HIV/AIDS in Africa: Ethical problems and Perspectives” on the complexities of PTCT. They underline that:
HIV-positive women who have access to services can also receive advice and support on how to reduce the risk of HIV transmission to their infants after delivery. Both the benefits of breastfeeding and the risk transmission of HIV through milk are of greatest significance in the first six months of an infant’s life. Although avoiding breastfeeding completely is the most effective way to avoid transmission, it carries other risks to infants and complications for mothers. Replacement feeding can be unsafe and expensive, and it increases the risk of infectious diseases. In areas where breastfeeding is the norm, mothers may be under pressure to conform to avoid suspicion and the stigma attached to HIV-positive status. This can result in mixed feeding (switching between breastfeeding and replacement feeding), which increases the risk of transmission because the infant gut can become damaged and provide entry for HIV infection. WHO recommends that replacement feeding should only take place where conditions make it acceptable, feasible, and affordable, sustainable and safe (Ray et al. 2002:x).
In fact, besides the affordability, accessibility, sustainability, feasibility that the writers mention, cultural acceptability is crucial. Failure to breastfeed a child in rural Ndau Zimbabwe, to which tribe the researcher belongs, means the mother is a witch, adulterer or has committed other socially unacceptable practices. Hence, a mother would rather stick to the societal norms than the safe practice, even though this means putting the child at risk.
Finally, it is important to point out that, though the semen, vaginal fluid, milk and blood have high HIV concentrations, which makes transmission possible, there are other conditions that should be met, i.e. human body temperature, moist environment, no contact with atmosphere, and right PH. The other risk-increasing conditions are entry point (opening or cut), sexually transmitted infections, and quantity of virus.
Table 2.1 HIV/AIDS statistics: HIV/AIDS by region (Source: http://www.avert.org/worldstats.htm)
Region Epidemic started # Adults & children living with HIV/AIDS Adult prevalence rate * # Adults & children living infected with HIV/AIDS Sub-Sahara Africa Late 70s-early 80s 25-28.2 million 7.5-8.5% 2.2-2.4 million North Africa and the
middle East
Late 70s- early 80s 470 000-730 000 0.2%-0.4% 35 000-50 000 South and East Asia Late 80s 4.6 –8.2 million 0.4- 0.8% 330 000-590 000 East Asia and Pacific Late 80s 700 000-1.3million 0.1 % 32 000-58 000 Latin America Late 70s-80s 1.3-1.9 million 0.5-0.7% 49 000-70 000 Eastern Europe and
central Asia
Early 90s 1.2-1.8 million 0,5%-0.9% 23 000-37 000 Western Europe Late 70s-Early 80s 520 000-680 000 0.3-0.3% 2600-3400 North America Late 70s –early 80s 790 000-1.2 million 0.5-0.7% 12 000-18 000 Australia and New
Zealand
Late 70s-Early 80s 12 000-18 000 0.1-0.1% Under 100 Caribbean Late 70s-80s 350 000-590 000 1.9%-3.1% 30 000-50 000 Total 40 (34-46 million) 1.1% (0.9-1.3%) 3 (2.5-3.5 million)
[ # The ranges around the estimates in this table define the boundaries
within which the actual numbers lie, based on the best available information. These ranges are more precise than those of previous years, and work is underway to increase even further the precision of the estimate that was published mid-2004.
[ Adults in this report are defined as men and women aged 15-49 and
children refers to the group 0-14 years. This age range captures those in their most sexually active years. While the risk of HIV infection continues beyond the age of 50, the vast majority of people with substantial risk behaviour are likely to have become infected by this age. Since population structures differ greatly from one country to another, especially for children and the upper adult ages, the restriction of 'adults' to 15-49 has the advantage of making different populations more comparable.
These figures can be represented graphically as follows:
HIV and AIDS Prevalence Rate For People Ages 15-49, 1998-1999 8.57% 0.12% 0.54% 0.06% 0.49% 2.11% 0.21% 0.23% 0.58% 0.13% 1.07% 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00% Sub-S aha ran A fric a North A fric a an d M iddl e Ea st South a nd S outh- E ast Asi a East Asia an d P aci fic La tin A meri ca Ca ribbean East ern Eu rope and Cen tral A sia We ste rn E urope Nor th Am eri ca Au stra lia an d N ew Zeala nd Wo rld Tota l (Source: http://www.princeton.edu/~ina/thematic_presentations/10-12)
Percentage of Adults and Children Living with HIV/AIDS, By Region, 1999
Sub-Saharan Africa 70% North Africa and Middle
East 1% South and South- East Asia
16%
Australia and New Zealand 0% Western Europe 2% North America 3% Caribbean 1% Latin America 4%
Eastern Europe and Central Asia
1% East Asia and Pacific
2%
HIV/AIDS By Gender and Region 55% 20% 35% 13% 25% 35% 25% 25% 20% 10% 47% 45% 80% 65% 87% 75% 65% 75% 75% 80% 90% 53% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Su b-Sah aran Afr ica Nort h Af rica and M iddl e Ea st Sout h and South - Eas t Asi a Eas t Asi a and Pa cific Latin Am eric a Carib bean East ern Eur ope and C entr al A sia We stern Eur ope Nor th A mer ica Aust ralia an d Ne w Z ealan d Wo rld To tal % HIV Postive Men % HIV Positive Women (Source: http://www.princeton.edu/~ina/thematic_presentations/10-12) HIV/AIDS struck very hard in poor countries as reflected above (Sub-Saharan Africa and South and East Asia): 96 percent of infected people are in the developing world, and 70 percent are in Sub-Saharan Africa alone (World Bank 2002 Online). According to the study by Globe Africa, by the end of 2002 an estimated 42 million people worldwide were living with HIV/AIDS. Over 30
million of them were in Sub-Saharan Africa. The reason5
for Africa’s high statistics is partly that “the virus has been present far longer in the communities of Africa. The virus originated in Africa, and then spread to other continents, as transport became more freely available and travelling became easier” (Christian AIDS Bureau 3.3/1).
Statistics a complex task: Statistics provide us with the general picture of what is going on. But one should be aware that statistics are complex and they can
5 The reasons for Africa’s high epidemic shall be discussed in detail in the following
be very misleading, depending on the motive of the researcher and presenter.6
An example would be that of the Zimbabwean government, which announced a reduction of statistical figures for HIV/AIDS from 33.7% to 27% (UN integrated regional information networks 2004:1). The figure went down further to 24.6% with a range of 20%-28% (Zimbabwe National HIV/AIDS estimates 2003:9). Before the new UNAIDS figure, the Zimbabwean government argued that the high figures presented by UNAIDS were Western propaganda to discredit Zimbabwe and President Mugabe.
An important factor that influences statistics and perceptions is the politicisation of information. Nierkerk (2003:167) in his article, “Mother-to-Child Transmission of HIV/AIDS in Africa: Ethical Problems and Perspectives”, discusses political influences on HIV/AIDS, issues focusing on the former adamant position of President Thabo Mbeki that HIV does not cause AIDS, thereby denying antiretroviral drugs to HIV/AIDS-affected people. Nierkerk aptly states, “One of the main complexities facing the management of the disease in Africa, is, therefore, this kind of politicisation of the discourse about AIDS” (see also Makgoba 2001:18; Gumede 2002:36-38; Makgoba 2000:30-31). These political influences make us to treat statistics with suspicion, though without denying that they provide a general picture.
Another important point to note is that in some countries HIV diagnosis and reporting systems are not reliable. Christian AIDS Bureau (4.4/4) notes that:
Due to under-diagnosis, under-reporting, and reporting delays, surveillance based on cases with clinical manifestations of the acquired immune deficiency syndrome is unreliable in most countries- especially those with weak health care systems.
It is crucial, therefore, for HIV/AIDS counsellors to remain informed on accurate facts and information, which is always changing. But how does HIV progresses in the body?
2.4
HIV/AIDS: Infection and Progress in Africa
HIV infection progresses through a number of stages until the person eventually dies. However, it is important to explain that these stages are not precisely demarcated into separate and distinct phases with easily identifiable boundaries. It is better to think of the stages as a progression. The stages are: the primary infection phase or acute sero-conversion illness, the asymptomatic latent phase, the minor symptomatic phase, the major symptomatic phase and
6 This sentiment was clearly expressed by Afredo Justino (a DTh student at Stellenbosch
University) from Mozambique; he indicated that the HIV/AIDS statistics provided by the Mozambican government are likely to be lower than the actual figures. The understatement is designed not to deter investors.
opportunistic diseases, and AIDS-defining conditions: the severe symptomatic phase (Van Dyk 2001:36; Jackson 2002:43; Ray et al. 2002:19; and others). The primary infection phase or acute sero-conversion illness: The phase begins at the time of infection when the person contracts the HI virus. After infection a person goes two to six weeks or several months with no signs or symptoms of disease and without detectable antibodies to HIV. An HIV (antibody) test at this time will be negative. This is called the “window period.” Sero-conversion refers to the point when the person’s HIV status converts or changes from being HIV negative to positive (antibody test). This normally occurs after four to eight weeks or more of the window period. The person would have a flu-like illness, fever-like symptoms with sore throat, headache, mild fever, fatigue, rash and oral ulcers. The person may not visit a doctor because the sickness is mild (Shelp and Sunderland 1987:11-13; Grenz and Hoffman 1990: 97-101; Jackson 2002:43; Van Dyk, 2001:36-53).
The asymptomatic latent phase: This stage can last from a few months to 10-15 years. The person will not show any signs of infection. The HI virus is present and destroying the immune system, but the person is not aware of this and appears healthy and normal. During this time the person may infect many other people. Jackson calls this stage the incubation period. The only symptom during this stage is persistent generalised lymphadenopathy (PGL) or swollen glands (Jackson 2002:43 and Van Dyk 2001:37; Ray et al. 2002:19).
The minor symptomatic phase: At this stage the early symptoms of HIV disease usually begin to manifest. Jackson calls this stage “HIV/AIDS-related illnesses”. The immune system is badly depleted and the HIV load has increased greatly. The symptoms include mild to moderate swelling of the lymph nodes in the neck, armpits and groin; occasional fevers; herpes zoster or shingles (which is a sign of low immunity); skin rashes, dermatitis, chronic itchy skin, fungal nail infections; recurrent oral ulcerations; recurrent upper respiratory tract infections; weight loss up to 10% of the person’s usual body weight; and malaise, fatigue and lethargy (Shelp and Sunderland 1987:11-13; Grenz and Hoffman 1990:97-101; Jackson 2002:43; Van Dyk 2001:38).
The major symptomatic phase and opportunistic infections: At this stage the opportunistic diseases start to take advantage of the deteriorating immunity. The viral load is very high and the CD4 cells are low. The following symptoms that are signs of immunity deficiency are evident: persistent and recurrent oral and vaginal Candida infections; recurrent herpes infections, such as herpes simplex (cold sores); bacterial skin infections and skin rashes; intermittent or constant unexplained fever that lasts for more than a month; night sweats; persistent and intractable chronic diarrhoea that lasts for over a month; significant and unexplained weight loss (more than 10% of normal body weight); abdominal discomfort; headaches; oral hairy leucoplakia (thickened
white patches on the side of the tongue); persistent coughing and reactivation of tuberculosis; various opportunistic diseases. At this stage the person is bedridden 50% of the day (Shelp and Sunderland 1987:11-13; Grenz and Hoffman 1990:97-101; Jackson 2002:43; Van Dyk 2001:38).
The AIDS-defining conditions - the severe symptomatic phase: At this stage the patient’s condition is referred to as “full-blown AIDS” and the body does not respond to antibiotics. These people are confined to their beds and usually die within two years. But in Africa they often die within one year because of the lack of drugs and correct nutrition. The World Health Organisation gave the following guidelines for the diagnosis of AIDS in Africa:
Major signs: weight loss of more than 10% of body weight; long-lasting diarrhoea; long-lasting fever, i.e. for over a month; major signs – persistent cough, over one month; generalised itchy skin disease; recurring shingles (herpes zoster); thrush in the mouth and throat; long-lasting, spreading and severe cold sores (herpes simplex); long-lasting swollen glands (PGL); loss of memory; loss of intellectual capacity; peripheral nerve damage (Jackson 2002:49).
The diagrams below (Fig. 2.3 and Fig. 2.4) show the stages of HIV progression in the body (CD4 cells and immunity weakening). In the diagram, both minor symptomatic and major symptomatic are under symptomatic.
Fig. 2.3: Stages of HIV progression
